Brighten Up

How to kiss age spots, freckles, and uneven skin tone goodbye

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Splashed across a little kid's cheeks, a smattering of freckles is charming. Later in life, though, extra facial pigmentation — in the form of brown patches or changes in tone and texture — sends a different, less adorable message: You're aging. Do people really notice each other's complexions that much? Apparently, yes. A 2006 Procter & Gamble Beauty study found that skin tone alone can impact a woman's perceived age — by as much as 20 years. So perhaps it's time to consider the slew of effective age spot treatments now available (some of them medical, some over-the-counter) that can deliver real, noticeable results.

Why do we get these spots, anyway?

Surprise: Age spots aren't caused by getting older. Instead, you can blame them (and nearly every other form of unwanted pigmentation) on what's become the 21st century's public enemy number one — the sun. "Sunshine is an attack on the skin, and one way the skin defends itself is to make pigment," explains Ranella Hirsch, M.D., a cosmetic dermatologist in Cambridge, MA, and president-elect of the American Society of Cosmetic Dermatology & Aesthetic Surgery. If a patient is skeptical about her spots being solar related, Dr. Hirsch asks her to move her bra over a quarter of an inch to expose the skin that the sun never hits. "And then she sees what I mean," she says. "If these changes really came from aging, you'd have them all over."

There's one way in which age spots are truly associated with passing years: The older most people get, the greater the amount of sun damage they've accumulated, so the spots are more numerous and more visible. "That's why sunscreen and sun avoidance are key to any therapy you try," says Debra Wattenberg, M.D., assistant clinical professor of dermatology at Mount Sinai Medical Center in New York City.

Why don't all spots look the same?

Even though most spots are caused — or exacerbated — by the sun, they take different forms. See a dermatologist if a new kind of skin change shows up (to rule out anything dangerous such as melanoma), but here's a guide to help you determine what's what.

Freckles: These are small tannish spots that are usually less than half a centimeter. They may come and go, fading in the winter and darkening in the summertime.

Lentigines: Known as age or liver spots, these small-to-medium brown areas multiply as you get older, popping up most often on the face, hands, and chest — all places with maximum exposure to sun.

Uneven skin tone: Rather than a few specific spots, this involves larger areas of pigmentation that make your skin look darker in some areas, lighter in others.

Post-inflammatory hyperpigmentation: These are dark spots that develop after pimples, bug bites, or other flare-ups, and then stubbornly remain long after the initial inflammation has healed.

Melasma: More patchy than spotty, these brown outbreaks are hormone related, so they are likeliest to appear (on the cheeks, forehead, and around the lips) when a woman is pregnant or taking hormone replacement or birth control pills.

How can I treat spots at home?

Try hydroquinone. This bleaching agent, available in department and drugstores or by prescription, works by interfering with an enzyme that helps your skin produce melanin, the brown pigment that shows up as spots. (Dr. Hirsch recommends using hydroquinone in conjunction with a prescription-strength retinoid, such as Renova or Tazorac, which helps lighten by exfoliating the skin.) "Hydroquinone is the gold standard for pigmentary disorders," says Rebat Halder, M.D., professor and chairman of the department of dermatology at Howard University. Look for it over the counter in concentrations up to 2 percent; prescription versions will usually have 4 percent.

Tip: Be careful to apply it only on the specific areas you want to lighten. "Hydroquinone is bleach," says Dr. Hirsch. "It can't distinguish the skin you want to bleach from the skin you don't." For precise application, she recommends using a Q-tip — or even an inexpensive eyeliner brush — to dot it directly on the spots.

Consider the alternatives. If you are sensitive to hydroquinone or prefer not to use it (see "Is Hydroquinone Safe?" below), you can improve the appearance of spots (probably less dramatically) with other over-the-counter treatments, including kojic acid, licorice extract, mulberry, vitamin C, and soy. "These are excellent alternative or additional therapies for pigmentation," says Dr. Wattenberg. "They do not all directly inhibit the enzyme that produces melanin, but they often produce results and are worth a try."

Retinols — the less potent, OTC form of retinoids — are also worthwhile options, especially if your skin can't tolerate the stronger versions. But keep in mind that results will be more about radiance and evenness (think softer, less noticeable spots), and less about the pigmentation being completely bleached away, says Dr. Hirsch.

To try: Neutrogena Visibly Even Night Concentrate ($12, drugstores).To skip: So-called brightening or lightening cleansers. They won't hurt you — but they also won't do anything more than wash your face. "They're not on the skin long enough to make a difference," says Dr. Hirsch.

Protect your results. "Sunscreen is essential," says Paul M. Friedman, M.D., clinical assistant professor of dermatology at the University of Texas at Houston. "Sun exposure can trigger production of the pigment you are trying to eliminate — and almost any treated dark spot can recur if exposed to UV light." And, yes, you still need the stuff if you have darker skin. A recent Johnson & Johnson study of hyperpigmentation in African-Americans found that participants who simply added an SPF 30 sunscreen to their daily routine (and used no other additional treatments) saw significant improvement in their pigmentation, skin tone, and radiance after eight weeks.

What can my derm do to help?

These days? A lot. "Dermatologists and plastic surgeons have a whole arsenal of light-based treatments available," says Dr. Friedman, who recommends pigmented-lesion lasers such as ruby, Nd:YAG, or Alexandrite for specific spots, and the Fraxel laser for allover improvement of substantial irregular pigmentation. For more subtle, diffuse discoloration, Dr. Wattenberg prefers a series of intense pulsed light photofacials. Some spots can be zapped in one session; more stubborn or severe discoloration can require multiple treatments. Another option: glycolic, alpha, or beta hydroxy acid peels, which slough off the surface layers of skin, softening the appearance of uneven tone. Some doctors will combine peels with laser or light therapy, and they will almost always prescribe at-home treatment as well. "In-office procedures are quicker, but they work best when accompanied by home therapy," says Dr. Wattenberg. Costs for most in-office treatments vary depending on several factors (the size of the area being treated, the severity of your condition, and the going rates where you live); the average is about $500 per session for pigmented-lesion lasers; $1,000 for Fraxel; $150 and up for peels. (Bonus: Many of the treatments will also help with wrinkles.)

How can I fix my skin's texture?

Skin damage is cumulative — so by the time you've lived through everything from breakouts to years of sun exposure, while at the same time your cells are producing less moisture and collagen, even good complexions eventually become somewhat bumpy and uneven. Can you return to a baby-butt level of smoothness? Sorry, no — but you can improve your skin's look and feel.

The best way: Boost collagen with the right products. "We lose a lot of collagen as we age, so we definitely need to compensate," says Dr. Hirsch, who recommends prescription-strength retinoids such as Renova (No. 9) and Retin-A. They're so good at stimulating collagen, "they should be in the water," she jokes. If you wish for an even more dramatic change, talk to your doctor about the in-office peels and laser treatments that are used to treat age spots — most also have a positive effect on texture.

The at-home way: To get quicker (though less dramatic) results, use a home-peel kit, says Dr. Hirsch. Know that highly abrasive isn't better; in fact, those products will irritate sun-damaged skin, she says. Instead, stick to chemical options and avoid harsh, grainy scrubs.

To try: Good Skin All Bright 2 Step Facial Peel Pads ($30, Kohls).

NEED TO KNOW

Is Hydroquinone Safe?

This effective spot-bleaching ingredient is banned in some European and Asian countries, largely because of studies in which cancer developed in rats that consumed extremely large amounts of it over extended periods of time. And last year, the FDA announced that it was reexamining the safety of hydroquinone. However, most U.S. experts — including the American Academy of Dermatology — stand firmly behind the drug. "Hydroquinone has been used over the last 40 years, and there has not been a single documented case of either skin cancer or internal cancer associated with it," says Dr. Friedman. Like all drugs, it needs to be used properly, and he recommends that his patients apply it no more than twice a day for no longer than six months. Adds Dr. Hirsch: "When used as intended, and for a finite time, this drug is safe and is the most effective treatment available for pigmentation. Period."

Found! At-Home Age Spot Options That Work

Many products promise to fade spots, but do they make a difference? To find out, the Good Housekeeping Research Institute had volunteers try various treatments for a four-week period. At two- and four-week intervals, they were examined by New York City dermatologist David J. Goldberg, M.D., using a Visia (a complexion-analyzing machine). Testers also rated the products on performance, ease of use, and satisfaction. So which one hit the spot? The winner with both the testers and the doctor was Murad Age Spot and Pigment Lightening Gel ($58, Sephora). Most volunteers who used this mix of glycolic acid and 2 percent hydroquinone showed a visible improvement in skin discoloration after just two weeks. If you'd prefer not to use hydroquinone, try our runner-up, Good Skin All Bright Spot Treatment ($15, Kohls). Though this blend of glucosamine, mulberry root, and yeast extract didn't lighten as noticeably as the Murad product, testers did experience results and liked that it was "nonirritating."